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new england

journal of medicine
The

established in 1812

february 25, 2010

vol. 362

no. 8

Mutations in the Lysosomal EnzymeTargeting Pathway


and Persistent Stuttering
Changsoo Kang, Ph.D., Sheikh Riazuddin, Ph.D., Jennifer Mundorff, M.A., Donna Krasnewich, M.D., Ph.D.,
Penelope Friedman, M.D., James C. Mullikin, Ph.D., and Dennis Drayna, Ph.D.

A bs t r ac t
Background

Stuttering is a disorder of unknown cause characterized by repetitions, prolongations, and interruptions in the flow of speech. Genetic factors have been implicated
in this disorder, and previous studies of stuttering have identified linkage to markers on chromosome 12.
Methods

We analyzed the chromosome 12q23.3 genomic region in consanguineous Pakistani


families, some members of which had nonsyndromic stuttering and in unrelated
case and control subjects from Pakistan and North America.
Results

We identified a missense mutation in the N-acetylglucosamine-1-phosphate transferase gene (GNPTAB), which encodes the alpha and beta catalytic subunits of GlcNAcphosphotransferase (GNPT [EC 2.7.8.15]), that was associated with stuttering in a
large, consanguineous Pakistani family. This mutation occurred in the affected
members of approximately 10% of Pakistani families studied, but it occurred only
once in 192 chromosomes from unaffected, unrelated Pakistani control subjects
and was not observed in 552 chromosomes from unaffected, unrelated North
American control subjects. This and three other mutations in GNPTAB occurred in
unrelated subjects with stuttering but not in control subjects. We also identified
three mutations in the GNPTG gene, which encodes the gamma subunit of GNPT, in
affected subjects of Asian and European descent but not in control subjects. Furthermore, we identified three mutations in the NAGPA gene, which encodes the
so-called uncovering enzyme, in other affected subjects but not in control subjects.
These genes encode enzymes that generate the mannose-6-phosphate signal, which
directs a diverse group of hydrolases to the lysosome. Deficits in this system are
associated with the mucolipidoses, rare lysosomal storage disorders that are most
commonly associated with bone, connective tissue, and neurologic symptoms.

From the National Institute on Deafness


and Other Communication Disorders
(C.K., D.D.), the National Human Genome
Research Institute (NHGRI) (D.K.), the Clinical Center (P.F.), and the Genome Technology Branch, NHGRI (J.C.M.), National
Institutes of Health all in Bethesda,
MD; the Center of Excellence in Molecular Biology, University of the Punjab, Lahore,
Pakistan (S.R.); and Hollins Communications Research Institute, Roanoke, VA
(J.M.). Address reprint requests to Dr.
Drayna at 5 Research Ct., Rm. 2B-46,
Rockville, MD 20850, or at drayna@nidcd
.nih.gov.
This article (10.1056/NEJMoa0902630) was
published on February 10, 2010, at NEJM
.org.
N Engl J Med 2010;362:677-85.
Copyright 2010 Massachusetts Medical Society.

Conclusions

Susceptibility to nonsyndromic stuttering is associated with variations in genes


governing lysosomal metabolism.

n engl j med 362;8

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677

The

n e w e ng l a n d j o u r na l

tuttering, also known as stammering, is a common speech disorder that has


been recognized since antiquity and affects
all populations and language groups.1 Although
the underlying causes of stuttering are unknown,
results of twin studies,2-6 adoption studies,7,8 and
family studies9,10 support a role for genetic contributions in the etiology of this disorder. Geneticlinkage studies have provided suggestive or significant evidence of linkage with numerous loci
across the genome.11-14 On the basis of a study
involving a group of consanguineous families in
Pakistan,12 the strongest linkage is with a locus
on the long arm of chromosome 12. We analyzed
this locus in a group of affected Pakistani families and in a series of affected but unrelated subjects from Pakistan, North America, and Britain,
as well as in unaffected, unrelated control subjects
from both Pakistan and North America.

Me thods
We analyzed families that had participated in previous linkage studies12 and focused on the largest family, designated PKST72 (Fig. 1). In addition, we studied unrelated cases of stuttering in
46 Pakistani subjects (one from each of the previously studied families12) and 77 additional unrelated persons with stuttering from Pakistan, as
well as 270 affected, unrelated persons from the
United States and England. This last group was
enrolled through public appeal, and potential
participants were required to meet the following
criteria on screening: age of 8 years or older; stuttering duration of 6 months or longer; evidence
of a family history of stuttering; and speech characterized by more than 4% stuttering dysfluencies,
as measured with the Stuttering Severity Instrument, 3rd edition (SSI-3),15 or a well-characterized
standard reading passage.16 The mean and the
overall distributions of dysfluency scores have
been shown to be similar with the use of these
two tests,15,16 and the distribution of scores with
the use of these two instruments in our population of stuttering subjects was similar as well
(see Fig. 1 in the Supplementary Appendix, available with the full text of this article at NEJM.org).
Young children, in whom recovery from stuttering is common, were excluded from the study;
also excluded were subjects who reported neurologic or psychiatric symptoms.
The ancestry of the Pakistani and North
678

n engl j med 362;8

of

m e dic i n e

AmericanBritish participants was determined by


self-report (see the Supplementary Appendix); all
Pakistani participants were Asian in origin, and
the affected North AmericanBritish participants
described themselves as white (206 participants),
black (25), Asian (16), Hispanic (13), Native
American (1), and other or unknown (9). The
mean (SD) age in our sample of affected, unrelated subjects was 30.712.1 years (for the age
distribution, see Fig. 2 in the Supplementary Appendix). The Pakistani control subjects consisted
of 96 age-matched and sex-matched persons with
normal speech from the same region of Pakistan.
The control subjects consisted of 276 well-characterized, neurologically normal North American
whites who were initially ascertained and evaluated as control subjects in a large study of Parkinsons disease (Coriell Institute for Medical Research).
All participants provided written informed
consent, and the study was approved by institutional review boards of the National Institutes of
Health and the Center of Excellence in Molecular
Biology in Lahore, Pakistan.
Gene identification and bioinformatic analyses were based on the UCSC Genome Browser,
March 2006 assembly. Comparative genomic hybridization17 was performed with the use of a
custom CGH 385K Array (NimbleGen), which
was designed to query 10 megabase pairs centered on base pair 99,197,889 (i.e., base pair
94,220,151 to base pair 104,175,626) of the chromosome 12 sequence in seven affected and three
unaffected Pakistani subjects. DNA sequencing
was performed on genomic DNA that was purified with the use of standard methods. Genetic
variants identified by sequencing were considered
for further analysis if they met the following
criteria: they had not previously been described
as a common single-nucleotide polymorphism in
the worldwide population (as indicated by an rs
number); they altered a known functional protein motif or resulted in an amino acid insertion
or deletion; they altered an amino acid that is
perfectly conserved in mammals; and they produced a prominent physical alteration, such as a
change in charge or polarity, in the amino acid.
Protein-sequence alignments were performed
with the use of MultAlin 5.4.1.18 Clinical evaluations included a medical history interview and
physical examination, a limited skeletal survey,
an echocardiographic examination, evaluations

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Lysosomal EnzymeTargeting Pathway and Stuttering

17

16
6

27
Ga

40

18
Ga

28

29

42
Ga

43

41

73
Ga

74
Ga

75
aa

76
aa

11

30
Ga

44

77
aa

78
aa

20

45

79
aa

47
Ga

13

33

15

48

34

49

84

85
Ga

24

35

50

51
Ga

64
Ga

82 83
Ga GG

14

23

63

81
aa

22

32

46

80
aa

12

21

31

62

72
Ga

10

19

52
GG

65
GG

86 87 88
Ga GG Ga

53

66
Ga

67
Ga

89
aa

54
Ga

55
GG

68
Ga

56
Ga

69
GG

Genotype

25

36

91
aa

92
aa

93
aa

94

95
aa

96
aa

97
aa

98

99

37

57
Ga

58
GG

70

71
Ga

38

59

39

60

61

No. of
Unaffected
Subjects

No. of
Affected
Subjects

4
9
2

3
13
12

GG (Glu/Glu)
Ga (Glu/Lys)
aa (Lys/Lys)
90
Ga

26

100 101

Figure 1. Pedigree and Distribution of GNPTAB Glu1200Lys Mutation in Family PKST72.


RETAKE:
1st
AUTHOR: Kang (Drayna)
Subjects 77 and 89 (green ovals) were homozygous for the mutation but were unaffected, suggesting
nonpenetrance. Subjects 65, 69,
2nd
FIGURE:
of 3 other affected subjects with respect to
3rdthe haplotype surrounding the gene for
and 83 (pink ovals) were affected but differed
from1 the
Revised
the alpha and beta subunits of N-acetylglucosamine-1-phosphate
transferase (GNPTAB). Double lines indicate consanguineous unions.
ARTIST: MRL
Squares denote male family members, circles female members, solid symbols affectedSIZE
and slashes deceased members.
7members,
col
TYPE:

Line

Combo

4-C

H/T

36p6

AUTHOR, PLEASE NOTE:


oligosaccharides Figure
and has
ofbeentwo
other
affected
Pakistani
redrawn
and type
has been reset.
Please check carefully.

of urine for excreted


families (Family
blood for lysosomal hexosaminidase activity, and PKST51 and Family PKST54); all three families
a dilated-pupil ophthalmologic examination.
gave nonparametricISSUE:
linkage
scores that supportJOB: 36208
2-25-10
ed linkage at this locus
not shown). We also
OLF: (data
2-10-10
sequenced
the
same
region
in three unrelated
R e sult s
Pakistani control subjects. No plausible geneticLinkage Study and Gene Evaluation
variant candidates were detected, so we enrolled
Previous results provided maximum evidence that more members of Family PKST72 and performed
a marker at the PAH gene was linked to stutter- additional two-point linkage analyses in this faming.12 We sequenced the 300-kb interval centered ily, including all the genotyped family members
on the PAH gene in five affected subjects: three shown in Figure 1. These analyses confirmed
from Family PKST72 (Fig. 1) and one each from linkage on chromosome 12q but resulted in maxn engl j med 362;8

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679

The

n e w e ng l a n d j o u r na l

imal linkage scores more proximally, with a peak


at the marker D12S1607 (Fig. 3 in the Supplementary Appendix). The results indicated that the
region from D12S101 to D12S1597 (extended from
base pair 94,220,151 to base pair 104,175,626 in
the March 2006 UCSC Genome Browser assembly) provided evidence for linkage in this family.
We undertook a systematic study of this 10-Mb
genomic region using a variety of methods, including comparativegenomic-hybridization microarray analysis and DNA sequencing. The microarray studies revealed no insertions, deletions,
or copy-number variants greater than 210 bp associated with stuttering in our test sample, which
included three affected persons from Family
PKST72, two from Family PKST54, and two from
Family PKST51, along with three unrelated, unaffected Pakistani subjects.
Within this 10-Mb region lie 87 known and
predicted genes (UCSC Genome Browser). DNA
sequencing of the exons, exonintron boundaries,
upstream regulatory regions, and 3! untranslated
regions of 45 genes residing within the region of
strongest linkage (Fig. 3 and Table 2 in the Supplementary Appendix) revealed numerous coding
variants in affected subjects. Segregation of these
variants was first tested in Family PKST72. Because these genes all reside within the region of
linkage, most of these variants cosegregated with
stuttering in this family more frequently than
would have been expected by chance. However,
most of these variants were found at high frequency in the unaffected Pakistani population
(>5%) and thus are probably nonpathogenic polymorphisms.
Mutations in GNPTAB

The variant showing the highest degree of cosegregation with stuttering in Family PKST72 was a
mutation (G3598A) that predicts the substitution
of a lysine residue for a glutamic acid residue at
position 1200 (Glu1200Lys) in GlcNAc-phosphotransferase (encoded by GNPTAB) (Fig. 2). With
three exceptions, the affected persons in Family
PKST72 carried one or two copies of this variant.
Further inspection of the affected noncarriers
showed that they carry common alleles at the adjacent marker D12S1607, whereas the 25 affected
family members carried either one or two copies
of the least common allele of D12S1607 in this
population (prevalence, 0.03). This suggests that

680

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of

m e dic i n e

the three noncarrier affected members stutter for


reasons unrelated to variation in the GNPTAB
gene. Two members of Family PKST72 were homozygous and nine were heterozygous for the
G3598A mutation but do not currently stutter. The
two homozygotes were females, who are known to
have a relatively high recovery rate in this disorder,1
and we hypothesize that they represent cases of
nonpenetrance. Thus, the G3598A variant does not
display absolute segregation with stuttering in
Family PKST72 under either a dominant or a recessive mode of inheritance; an additive genetic model
is more consistent with the pattern of inheritance
of the trait. The fact that the highest linkage scores
were obtained for the GNPTAB G3598A variant,
combined with the lack of other plausible genetic
variants within the linkage interval, suggested that
this variant increases the risk of stuttering when
present in either one or two copies.
We then screened for this and other potential
mutations in GNPTAB in additional affected, unrelated Pakistani persons, including 1 affected
member from each of the 46 families analyzed
in our previous linkage study,12 and in 96 unaffected matched Pakistani control subjects. We
also screened 270 affected, unrelated North
AmericanBritish subjects and 276 unaffected
North American matched control subjects. Subsequent DNA sequencing of the 21 exons, the
exonintron boundaries, and the 5! upstream promoter region of the GNPTAB gene in all cases and
all controls revealed that the Glu1200Lys variant
occurred in affected subjects in three other
Pakistani families (PKST5, PKST25, and PKST41)
from our previous linkage study,12 in one affected
North American person of Asian Indian ancestry, in two affected, unrelated Pakistani subjects,
and in one Pakistani control subject. This mutation thus appears to be most common in populations from the Asian subcontinent. We identified
three other potential mutations in four affected,
unrelated subjects, as summarized in Table 1.
None of these variants were observed in the 192
chromosomes from unaffected Pakistani control
subjects or in the 552 chromosomes from neurologically normal North American control subjects. Comparative analysis revealed that the normal amino acid at each of these four positions
in GNPTAB is conserved in all vertebrates (Fig. 2),
further supporting the view that these variants
represent pathologic mutations.

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Lysosomal EnzymeTargeting Pathway and Stuttering

GNPTAB

GNPTAB c.961AG
(p.Ser321Gly)

Homo sapiens
Macaca mulatta
Canis lupus
Bos taurus
Mus musculus
Rattus norvegicus
Gallus gallus
Danio rerio

GNPTG

GNPTAB c.1363GT
(p.Ala455Ser)

CTGCCNGTCGT
321
SKQDEDISASRFEDNEELRY
SKQDEDISASRFEDNEELRY
SKQDEDVSASRFEDNEELRY
SKQDEDVSASRFEDNEELRY
SKQDEDVSASRFEDNEELRY
SKQDEDVSASRFEDNEELRY
SKQDEDISASRFEDNEELRY
SKQDEDVSASRFEDNEELRY

ACAAGNCTTGT
455
IKDGYCDKACNNSACDWDGG
IKDGYCDKACNNSACDWDGG
VKDGYCDKACNNSACDWDGG
IKDGYCDKACNNSACDWDGG
IKDGYCDKACNNSACDWDGG
IKDGYCDKACNNSACDWDGG
IKDGYCDKACNNSACDWDGG
IKDGYCDKACNNSACDWDGG

GNPTG c.11_19dup
(p.Leu5_Arg7dup)

Homo sapiens
Pan troglodytes
Rattus norvegicus
Mus musculus
Gallus gallus

NAGPA

TGCAGNGAAGA
74
AGGPAPAGAAKMKVVEEPNA
ARGPAPAGAAKMKVVEEPNS
AQGPAPTHAGKMKVVEEPNT
SQGPAPACAGKMKVVEEPNT
AALGVLASAGKMKIVEEPNT

NAGPA c.252CG
(p.His84Gln)

Homo sapiens
Macaca mulatta
Bos taurus
Rattus norvegicus
Mus musculus
Gallus gallus

GAGTTNAAAAT
624
NLTFQNTNDEEFKMQIFVEV
NLTFQRTNDEEFKIQITVEV
NLTFQNTNDEEFKIQITVEV
NLTLQGKNDEEFKIQIVVEV
NLTLQNANDEEFKIQIAVEV
NLTLQNSNDEEFKIQIAVEV
NLTFLNKNDEEFKMQVAVEV
NITFQSTDHHDFIMTFSVSV

GNPTG c.74CA
(p.Ala25Glu)

AGCCNCGCCNN
5
MAAGLARLLLLLGLSAGGPA
MAAGLARLLLLLGLSARGPA
MAGRLTGFLMLLGLAAQGPA
MAGRLAGFLMLLGLASQGPA
..MAAARLLLAVFVGAALGV

AACCCNGCTGC
328
STVVCVHEPRCQPPDCHGHG
STVVCVHEPRCQPPDCHGHG
STVVCVHEPRCQPPDCSGHG
STVVCVHEPRCQPPNCSGHG
STVVCVHEPRCQPPDCSGHG
STIVCVHEPACEPADCSGHG

TGCAGNAATGG
1200
RFLHMHELQEWRAYRDKLKF
RFLHMHELQEWRAYRDKLKF
RFLHMHELQEWRAYRDKLKF
RFLHMHELQEWRAYRDKLKF
RFLHMHELQEWRAYRDKLKF
RFLHMHELQEWRAYRDKLKF
RFLHMHELQEWRAYRDKLKF
RFLHMTELQEWRIYRDKLKF

GNPTG c.688CG
(p.Leu230Val)

CCCAGNTGGAG
688
KTPEENEPTQLEGGPDSLGF
KTPEENEPTQLEGGPDSLGF
KVPGETHPTQLAGDSKGLGL
KVPGETHPTQLAGGSKGLGL
KATEEKE.AEKQNMKTSLQF

NAGPA c.982CT
(p.Arg328Cys)

TCGCANTTCAG
84
GLAVRTFVSHFRDRAVAGHL
GLAVRTFVSHFRDRAVTGHL
RPSVRTFVSYFADRAVPGHL
RAAVRTFVSHFEGRAVAGHL
HAAVRTFVSHFEGRAVAGHL
RCCTRTFVSYVRRRAVYGHF

GNPTAB c.3598GA
(p.Glu1200Lys)

GNPTAB c.1875CG
(p.Phe624Leu)

NAGPA c.1538_1553del
(p.Phe513SerfsX113)

CCCCTNNANNN
513
GEPLAAEKEQPGGAHNPFKD
GELLAVEKEQPGGAHNPFKD
GEHPAAEKEQLGDSSNPFKD
GDALAAEKEQTEETCNPFKD
GEALTAEKEHMEETSNPFKD
GCA.................

Figure 2. Mutations Found in GNPTAB, GNPTG,


NAGPA
and Alignment of Their
Amino Acid
RETAKE:
1st Sequences in Different Species.
AUTHOR:and
Kang
(Drayna)
2nd
Shaded areas indicate amino acid changes resulting from mutations in various species. In NAGPA,
p.Phe513SerfsX113 denotes a frameFIGURE:
2 of 3and creates a new reading frame that ends
3rd in a stop 113 amino acids downstream
shift mutation that changes phenylalanine 513
to serine
Revised
(see Fig. 4 in the Supplementary Appendix, ARTIST:
availableMRL
with the full text of this article at NEJM.org). GNPTAB denotes the N-acetylglucosaSIZE
mine-1-phosphate transferase gene encoding the subunits alpha and beta, GNPTG the 7N-acetylglucosamine-1-phosphate
transferase
col
Combo
4-C
H/T
TYPE:the Line
36p6 alpha-N-acetylglucosaminidase gene.
gene encoding the subunit gamma, and NAGPA
N-acetylglucosamine-1-phosphodiester
AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset.
Please check carefully.

Evaluation of Genes within the Pathway

JOB: 36208

We then sequenced the 11 exons, the exonintron


boundaries, and the 5! upstream promoter region
of the GNPTG gene, which encodes the recognition subunit of GlcNAc-phosphotransferase,19,20
in all case subjects and all control subjects. We
identified three mutations in four affected, unrelated persons (Table 1). None of these variants

n engl j med 362;8

were present in a total


of 192 chromosomes from
ISSUE: 2-25-10
Pakistani control subjects or in 552 chromosomes from North American control subjects.
The missense mutation observed at amino acid
position 74 encodes a negatively charged glutamic acid in place of the small, nonpolar amino acids (alanine and glycine) at this position in mammals and the chicken (Fig. 2). The mutation at

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681

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

Table 1. Mutations Found in GNPTAB, GNPTG, and NAGPA.*

Gene

Mutation

Change in
Amino Acid

Pakistani
Pakistani
Case Subjects Controls
(N = 123)
(N = 96)

North American
British
North American
Case Subjects
Controls
(N = 270)
(N = 276)

no. of mutant alleles


GNPTAB
Exon 9

c.961AG

p.Ser321Gly

Exon 11

c.1363GT

p.Ala455Ser

Exon 13

c.1875CG

p.Phe624Leu

Exon 19

c.3598GA

p.Glu1200Lys

c.11_19dup

p.Leu5_Arg7dup

GNPTG
Exon 1
Exon 2

c.74CA

p.Ala25Glu

Exon 9

c.688CG

p.Leu230Val

Exon 2

c.252CG

p.His84Gln

Exon 6

c.982CT

p.Arg328Cys

p.Phe513SerfsX113

NAGPA

Exon 10 c.1538_1553del

* GNPTAB denotes the N-acetylglucosamine-1-phosphate transferase gene for the alpha and beta subunits, GNPTG the
N-acetylglucosamine-1-phosphate transferase gene for the gamma subunit, and NAGPA the N-acetylglucosamine-1phosphodiester alpha-N-acetylglucosaminidase gene.

position 688 encodes a valine in place of leucine


that occurs at this position in all mammals. The
third mutation was a 9-bp duplication, encoding
an in-frame duplication of amino acids 5, 6, and 7.
The GlcNAc-phosphotransferase enzyme encoded by GNPTAB/G acts in the pathway that generates
the mannose-6-phosphate targeting signal that
directs enzymes to the lysosome21 (Fig. 3). The
subsequent step in this pathway is catalyzed by
N-acetylglucosamine-1-phosphodiester alpha-Nacetylglucosaminidase (NAGPA, EC 3.1.4.45), also
known as the uncovering enzyme (see Fig. 3 for
an explanation). Sequencing the 10 exons, the exonintron boundaries, and the 5! upstream promoter region of NAGPA in all cases and all controls revealed three different mutations in six
unrelated affected persons (five heterozygotes and
one homozygote) (Table 1). None of these variants
were present in a total of 192 unaffected Pakistani
and 552 unaffected North American control
chromosomes. The mutation at amino-acid position 328 encodes a cysteine in place of an arginine
that is conserved in all known mammals, while
the mutation at amino-acid position 84 encodes
a glutamine in place of the normal histidine that
occurs in humans, chimps, rats, and mice (Fig. 2).
682

n engl j med 362;8

The third mutation was a 16-bp deletion that


changes the penultimate amino acid from lysine
to asparagine and removes the last amino acid
and the stop codon, resulting in an extended
open reading frame that predicts the addition of
112 amino acids to the carboxyl terminus of this
protein (Fig. 4 in the Supplementary Appendix).
In summary, we observed mutations in GNPTAB,
GNPTG, and NAGPA in 25 of 786 chromosomes
from unrelated case subjects, as compared with
4 of 744 chromosomes from control subjects (chisquare = 12.476, 1 df; P = 0.0004) (Table 3c in the
Supplementary Appendix).
Mutations in GNPTAB and GNPTG have been
associated with the rare inherited lysosomal storage disorders mucolipidosis types II and III, respectively,21,22 which are characterized by disorders
of the joints, skeletal system, heart, liver, spleen,
and motor systems and by developmental delay.
Mutations in NAGPA have not been reported.
Clinical Examinations

Because the affected cases in our study were ascertained on the basis of having nonsyndromic
stuttering, we interviewed and carried out a more
detailed clinical examination of three affected

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Lysosomal EnzymeTargeting Pathway and Stuttering

-+/,'&"0-+)03#%%*#2+&'"7+4*"
4'2.+/#-".#//03'"2'3+&5'

 

;-%%

P
P

/%06'2+/)"
'/:9.'"
'/%0&'&"$9"
NAGPA

+
-%%

93030.#-"*9&20-#3'"
7+4*" "'8103'&

-%%1*031*042#/3('2#3'"4*'"
%0.10/'/43"0("7*+%*"#2'"'/%0&'&"
$9"GNPTAB"#/&"GNPTG

-%%

/&030.'

#//03'
P

*031*#4'
93030.'

2+&+/'

Figure 3. Tagging for Transport of Lysosomal Enzyme.


In the first step, GlcNAc-phosphotransferase (the alpha, beta, and gamma subunits of which are encoded by the GNPTAB and GNPTG
genes) catalyzes the covalent linkage of GlcNAc-1-phosphate from uridine diphosphate (UDP) to the terminal mannose residues of the
N-linked oligosaccharides on enzymes destined for the lysosome. In the second step, NAGPA (N-acetylglucosamine-1-phosphodiester
alpha-N-acetylglucosaminidase), also known as uncovering enzyme, removes one GlcNAc group, thereby exposing mannose-6-phosphate
(M6P), which acts as the targeting signal. Enzymes with this targeting signal are then routed through the Golgi apparatus to the lysosome.

persons: two of whom were heterozygous carriers


of the Ala455Ser mutation in GNPTAB, and one of
whom was homozygous for the Arg328Cys mutation in NAGPA. These three persons did not have
the signs or symptoms typically seen in mucolipidosis types II and III.21 None of the three subjects had a history of developmental delay, and
they have had 17, 14, and 17 years of education.
On physical examination, none of the three were
dysmorphic or had abnormalities of the skeleton,
joints, eyes, or heart. Limited skeletal surveys
showed no evidence of a dysostosis multiplex.
Other than stuttering, which ranged in severity
from mild to moderate-to-severe, neurologic findings were within normal limits. Elevated levels of
urinary oligosaccharides, which are characteristic of some lysosomal storage disorders, were not
observed. In these three subjects, plasma betahexosaminidase values were 29.0, 9.8, and 15.0 U
per liter (normal range, 10.4 to 23.0).

likelihood of nongenetic and heterogeneous


causes. These factors make it probable that unaffected persons can carry mutations associated
with stuttering (i.e., may have nonpenetrant mutations) and that affected persons may not carry
such mutations (i.e., may represent phenocopies).
In addition, our findings in Family PKST72 are
consistent with the possibility of assortative mating, in which preferential matings between affected persons or families can lead to stuttering
caused by different mutant alleles within one
large family. Three findings support a pathogenic
role of these mutations in stuttering: only one of
these GNPTAB, GNPTG, and NAGPA mutations was
observed in the unaffected control subjects (i.e.,
in a single chromosome); all the mutations oc- !'23+0/"
 
54*02
2#9/##/)
curred at positions at which amino acid identity
+)"

is conserved to a large extent across species; and
+4-'
'23+34'/4"34544'2+/)

"
all the mutations occurred within a single, well

defined metabolic pathway. Further supporting24+34
a

 ""
causative role of these mutations in stuttering is
+)52'"*#3"$''/"2'&2#7/"#/&"491'"*#3"$''/"2'3'4
-'#3'"%*'%,"%#2'(5--9
the
observation
that
although
persons
with
muDiscussion
335'"&#4' 

colipidosis types II and III predominantly have
Genetic studies of stuttering are complicated by skeletal, cardiac, and ocular disorders, they often
the high rate of spontaneous recovery in this dis- have deficits in speech, particularly in expressive
order, especially among females,23 and by the speech.24-26 These deficits have been viewed as
n engl j med 362;8

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" 

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683

The

n e w e ng l a n d j o u r na l

secondary to the developmental delay that is typical in these disorders, but the sparing of some
intellectual functions in mucolipidosis type III25
suggests that speech deficits may be primary
rather than secondary in this disorder.
There may be several reasons why the mutations we identified in GNPTAB and GNPTG result
in stuttering rather than in mucolipidosis types
II and III. First, mucolipidosis types II and III are
generally believed to be autosomal recessive disorders, and all the unrelated affected persons in
our sample, with two exceptions, were heterozygous and thus not expected to have either of these
disorders. Another possibility is that all but one
of the mutations we identified are missense
rather than protein-truncation or deletion mutations, which are typically observed in mucolipidosis types II and III, and presumably have a
more severe effect on protein function. None of
the mutations we observed in GNPTAB and GNPTG
have been identified in persons with mucolipidosis type II or type III.27-30
No human disorder has yet been associated
with mutations in NAGPA. This could be viewed as
surprising, given that such mutations are predicted to have an effect on many different lysosomal
enzymes. Our study suggests that a primary consequence of NAGPA mutation is nonsyndromic,
persistent developmental stuttering.
An important reason to investigate stuttering
is to better understand the neural structures and
functions within the brain that generate human
speech, which are poorly understood. Data regarding expression of these three genes in the
human brain is limited. Data for the mouse brain
are available for NAGPA and GNPTG. GNPTG has
the most localized expression in the brain, with
high levels of expression in the hippocampus,
hippocampal formation, and cerebellum (accord-

of

m e dic i n e

ing to the Allen Brain Atlas31). These structures


are associated with, among other things, emotion
and motor function. A persons emotional state
can exert a strong effect on the severity of stuttering.1 In addition, whereas stuttering does not
affect the ability to conceptualize words and
sentences, it does affect the motor functions
required for fluent speech. These three genes are
widely expressed in many tissues in the body
throughout life, and lifelong expression of these
genes is consistent with the persistent nature of
stuttering in our subjects.
We found NAGPA mutations only in persons of
European descent, and these mutations occurred
in 6 of the 270 affected North AmericanBritish
subjects (2%). We observed mutations in GNPTAB
and GNPTG in 15 of 393 affected persons who
were of South Asian or European descent (4%).
Persistent stuttering affects approximately 1% of
the U.S. population, corresponding to about 3 million people, and an estimated 60 million people
worldwide. Although our results can explain only
a small fraction of cases of stuttering, these
susceptibility variants are likely to be present in
a large number of affected persons. Our findings also suggest that manifestations of mutations in these genes are not limited to the very
small number of people who have frank symptoms of mucolipidosis type II or III. Rather, the
manifestations of lysosomal targeting deficits
may be present in a larger group of patients
commonly encountered in medical practice.
Supported by grants from the Intramural Research Program
of the National Institute on Deafness and Other Communication Disorders (Z01-000046-09, to Dr. Drayna) and the National
Human Genome Research Institute (to Dr. Mullikin).
No potential conflict of interest relevant to this article was
reported.
We thank the Stuttering Foundation of America, the National
Stuttering Association, the British Stammering Association, and
the subjects who participated in the study for their support.

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685